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LEGAL LAWS

ETHNICAL PRINCIPALS

• Advocacy: supports a person’s health, wellness, safety, privacy, and personal rights.
• Responsibility: respect obligations and follow through on promises.
• Accountability: willingly taking responsibility for one’s own actions.
• Confidentiality: protection of a person’s privacy.
• Autonomy: a person’s right to make own decision.
• Beneficence: act of kindness and doing good for others.
• Fidelity: keeps promises and fulfills them.
• Justice: fair treatment of giving safe and quality care to each individual.
• Non-maleficence: commitment to do no harm.
• Veracity: commitment to telling the truth.

CLIENT RIGHTS

• 1972 A Patient’s Bill of Rights adopted by AHA.
• Client’s rights must be respected and NURSES are responsible for protecting the rights of the client.
• Client has the right to details of procedures, informed consent, advance directives, & confidentiality of information
• Client has the right to REFUSE/DISCONT INUE treatment/medication/etc. (whether admission is voluntary or involuntary)
• Client has the right to be active in decision-making of care plan, accept/refuse/modify care plan, receive competent care & respect.

TORT: Person injured due to another person’s unintentional or intentional failure to act. Injury can be physical, emotional, or financial.

Unintentional tort: negligence

• Negligence: person harmed due to neglected duties, procedures, or precautions.
  • FAILURE TO: follow standard protocols; report equipment malfunctions; give standards of safe care; prevent injuries; question physician’s incorrect orders; AND performing procedures you were NOT taught.
• Malpractice (Professional Negligence): improper or injurious treatment from a licensed person’s actions or lack of actions.

Intentional tort: assault, battery, false imprisonment, etc.

• Assault: threat or attempt to do bodily harm > telling elder his/she will take a shower even if he/she refused.
• Battery: physically touching someone or his/her possessions w/o consent > beating person, caring out procedures the person refused, forcing person out of bed, etc.

Quasi-Intentional:

• Libel: written statement or photo that is false of damaging.
• Slander: malicious verbal statements that are false or injurious > gossip & exaggeration.
• Defamation: act that harms a person’s reputation.

CRIME: Intentional wrong doing against another person, people, or environment. Considered both felony & misdemeanor.

LIABILITY: Deliberate “commission” of a forbidden act or “omission” of an act required by law.

• “act of commission” > participating in illegal abortion, giving person wrong med & is harmed, etc.
• “act of omission” > person not given scheduled med & is harmed, failure to report elder or child abuse, etc.

> Felony: serious crime > insurance fraud, practicing w/o license, theft of narcotics, etc. > Misdemeanor: not serious as felony, but still a crime > possession of controlled substances, etc.

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1. ASSESSMENT: - Subjective data (what the patient tells you; chief complaint) and Objective data (what you, as the nurse, observes); interview (medical history); Head-to-Toe Assessment Analyze Data:
   • Recognize significant data (which data is relevant or not to the patient’s care)
   • Validate observations (“check them out”)
   • Recognizing patterns (when does the symptom occur? Night, after eating, certain position, etc.) and clusters (relationship among symptoms). Ex: abdominal pain, bloating, and NO bowel movement in 3 days
   • Identifying strengths (ways patient can cope with problem) and problems (actual or potential problems)
   • Analyzing data to reach conclusions (no problem; may have problems; risk of problem; or clinical problem)
   • Continuously update information

SCOPE OF PRACTICE

RN

• Hang & administer blood
• Initial assessment on admitted patient
• Patient care plan
• Discharge teaching
• Start IV & administer IV meds
• Performs same duties as LPN/LVN & UAP

LPN/LVN

• Reinforce client teaching taught by RN
• Report ABNL findings to RN & HCP
• Performs more “skill” procedures
• Tracheostomy care & suctioning
• Check NG tube latency
• Enteral feedings
• Insert urinary catheters
• Administer meds

UAP

• ADL (activity of daily living): hygiene, dressing, ambulating, feeding (NO aspiration risk pts.), bathroom breaks
• Position & transfer (bed to chair, chair to bed)
• Bed-making
• Specimen collection
• I&Os
• Vital signs (stable patients)

In some states, CANNOT give IV meds

DO NOT delegate, teach, demonstrate, explain, & use clinical judgement

• RN delegates the LPN/LVN and UAP
• LPN/LVN delegates UAP
• Right task
• Right circumstance
• Right person
• Right direction & communication
• Right supervision & evaluation

FIVE RIGHTS OF DELEGAT IONS

NURSING PROCESS

1. DIAGNOSING: - Statement about the actual or potential health problem of the patient that can be managed through independent nursing interventions

• Medical Diagnosis vs Nursing Diagnosis
• Three Components of a Nursing Diagnosis: P – Problem E – Etiology (cause) S – Signs and Symptoms (objective and subjective data)
• Writing a Diagnostic Statement:
• Example: Fluid Volume Deficit (P) related to physiologic effects of dehydration (E) as evidence by dry mucous membrane, increased HR and RR, poor skin turgor, orthostatic hypotension, and fatigue (S).

1. PLANNING: - Development of goals to prevent, reduce, or eliminate problems and identify nursing interventions (actions taken) that will help client in meeting goals.

• Set priorities (survival needs or imminent life-threatening problems is highest priority; Maslow’s Hierarchy of Needs and ABCs)
• Establish expected outcomes (client-oriented, specific, reasonable, and measurable)

• Short-term objective (goal met in hours or few days) vs Long-term objective (goal require longer time to accomplish)

• Select nursing interventions (orders or actions taken to help client reach goal)
• Write nurse care plan (formulated by entire nurse team)

1. EVALUATION: - Analyze client’s response (measure client’s progress; were the goals met?)
   • Identify factors contributing to success or failure of care plan
   • If care plan was not successful, modify goals and/or interventions and rewrite care plan
   • Discharge (problems are resolved; client’s plan is individualized; healthcare team conference with client and family to discuss continued or new goals at home; next visit/ follow-up)
   • Plan for future nursing care
2. INTERVENTIONS: - “Do it” - putting nurse care plan in action
   • Continue collecting data (observe carefully, listen to what client says, watch what they do, check vital signs)
   • “Share it” - discuss client’s progress or setbacks with nurse team
   • “Write it down” - document care given

NURSING PROCESS

CLIENT SAFETY

RESTRAINTS & SECLUSION

Types: human, mechanical, chemical, & physical device

Considerations:

• LAST measure used if less restrictive interventions does NOT work (diversion, frequent observations, calm/quiet environment, etc.)
• Prescribed for the SHORT EST DURAT ION as possible
• ALWAYS a Physician’s order (written)
• Prescription should be renewed every 24 hrs (if still needed)
• Prescription must include reason, type, location, duration, and type of behavior that permits use of restraint.
• ALWAYS check the facility’s policy on restraints
• NOT given as PRN
• Restraints SHOULD NOT
  • Intend to harm the patient
  • Be used for convenience, punishment, or for patients who are physically or emotionally unstable.
• Assess neurovascular & circulation status and skin integrity (pulse, blood pressure, pulse ox, color, movement, pain) every 30 mins
• Documentation every 15-30 mins
  • Reason, type of restraint, date & time, duration, neuro/circulation/skin assessment checks, evaluation of behavior for need to discontinue or prolong restraint use, client’s behavior, medications given, vital signs, food & fluid intake, bathroom use

Side Rails:

• Top 2 are used and bed at lowest height.
• NOT considered restraint when used to prevent sedated person from falling out of bed.

Physical device:

• 2 finger width of space between restraint and patient
• Use quick-release knot to tie restraint to bed frame
• Remove every 2 hrs. Have patient perform ROM.
• Monitor neurovascular status and skin integrity every 30 mins. (pulse, skin color, movement)

THERAPEUTIC COMMUNICATION

Do’s Dont’s

Nonverbal Cues (eye contact, nodding)

”Don’t Worry” Disregardes their concerns

Why? Why did you do that?

Closed-Ended Questions “Yes or No” (Except in Self-Harm)

What? What makes you feel that way?

Open-Ended Questions How are you feeling today?

Clarifying Techniques Restating: use the client's precise words Paraphrasing: Restate the client's opinions to confirm what they said. Exploring: allows the nurse to collect additional information

Therapeutic communication is a communication approach that uses verbal and nonverbal gestures to address a patient's physical and emotional needs.

Assertive: expressing sentiments or wants clearly without infringing on the rights of others “I respect your feelings and here are mine...” Aggressive: expressing feelings and thoughts in a loud manner that violates the rights of others “I am never wrong!” Passive: evading or neglecting to express individual feeling or wants. “I don’t care about this.” Passive Aggressive: On the appearance, passive, yet after discourse, covert hostility, either alone or with others. “That is fine, but don’t be surprised if others get mad.”

Types of Communication

Incivility: harsh words or actions (sarcasm, eye roll) Bullying: repeated threats or intimidation Lateral Violence: peers' abusive comments or deeds (gossip, threats, defamation)

Communication Between

Interdisciplinary Team

1. Is there actions illegal?

Yes Report to Supervisor No Go to #

1. Is anyone in physical or psychological harm?

Yes Confront and take over to keep others safe. No Go to #

1. Is the behavior simply inappropriate?

Yes Talk to them regarding your concerns at a convenient time.

Inappropriate Behavior of Staff

OSMOSIS & SOLUTION TYPES

Equal concentration on either side of the semipermeable membrane.

• 0.9 % normal saline (NS)
• 5% dextrose in water (D5 W)
• 5% dextrose in 0.225% normal saline (D5 1/4 NS)
• Lactated Ringer’s

Solution has higher concentration of solute compared to a less concentrated solution. Fluid leaves the cell & causes the cell to shrink & shrivel from dehydration.

• 5% dextrose in Lactated Ringer’s
• 5% dextrose in 0.45% normal saline (D5 1/2 NS)
• 5% dextrose in 0.9% normal saline (D5 NS)
• 10% dextrose in water (D10 W)
• 3% normal saline
• 5% normal saline

Solution has lower concentration of solute compared to a more concentrated solution. Fluid enters the cell & causes the cell to swell & sometimes burst b/c of excess fluid.

• 0.45% normal saline (1/2 NS)
• 0.225% normal saline (1/4 NS)
• 0.33% normal saline (1/3 NS)

ISOTONIC (NORMAL) HYPOTONIC (DILUTED) HYPERTONIC (CONCENTRATED)

CENTRAL VENOUS ACCESS DEVICE

A central venous access device is a type of IV therapy where a tube is inserted into a large VEIN that ends in the superior vena cava. Can last several weeks to years. Uses:

• Parenteral Nutrition
• Chemotherapy Administration
  • Parenteral Nutrition
    • Blood Administration
    • Burn or Trauma Resuscitation
    • Antibiotics Administration

PICC Line: Central catheter placed from the outside.

• Access to the Basilic Vein
• Clots or infections are extremely likely
• The gadget is not sutured and can be removed by the nurse Port-A-Cath: a surgically implanted device with a catheter linked to a subcutaneous pocket
• Common with Chemo Patients Tunneled: put into vein through skin, generally in the chest
• Usual in a Domestic Setting
• Long-Term Application
• Reduced Infection Risk
• Catheter with cuff attached to anchor it to the skin Hemodialysis: central catheter (temporary)
• Larger Lumen = Faster Flow
• Short Term Application

Types of Central Lines

• Maintain Line Patency Use Push/Pause method to risk of clots 10 mL of sterile 0.9 NS flush
• Dressing Care Check that the dressing is clean, dry, intact Dressing Changes Every 7 Days
• Infection Control Change Injection Cap on Lumens Q7 days Use an Antimicrobial Patch (CHG) Keep an eye out for Infection Signs Sterile Gloves During Dressing Care

Central Line Care

A lumen is an aperture at the distal end of a catheter that can be used to infuse or aspirate fluids. Number of Lumens = Diameter of Each Lumen Single Lumen: Sheath with a big bore for quick or massive infusions. Multiple Lumen: used to give many incompatible medications

Lumen Types

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PATIENT POSITIONING

Supine: “On my Spine”: Flat on Back

Uses: neck or spinal cord injuries, abdominal or facial surgery

Prone: “Away from that Tailbone”: Flat on Stomach

Uses: advanced acute respiratory distress syndrome, spinal cord operations

SIMS: On your stomach, with your leg

flexed and your arm flexed at the elbow. Uses: evaluating the rectal, vaginal areas

Fowlers: Sitting Up

Low Fowlers: 15-30° Semi Fowlers: 30-45° High Fowlers: 60-

Uses: tube feeding or maintain ICP in neuro patients

Lithotomy: Flat on your back, knees

bent, and feet on stirrups Uses: examine the genitalia, reproductive tract, and rectum of the female.

Trendelenburg: Lay flat on your back with

head lowered below the level of your feet. Uses: air embolism, central line placement, hypotension

Reverse Trendelenburg: Flat on

back, with your head elevated above your feet. Uses: GERD, pulmonary aspiration prevention

Lateral: Patient on Side

Uses: one sided injuries

URINARY ELIMINATION

PRESSURE ULCERS

Urinary frequency: voiding more than usual Urgency: sensation to void immediately; common to experience involuntary leakage Dysuria: difficulty urinating due to pain and burning sensation (associated w. infection) Nocturia: frequent voiding at night Enuresis: "bedwetting" Polyuria: excessive excretion of urine; >2,500 mL/day is considered polyuria Oliguria: litt le excretion of urine; <500 mL/day is considered oliguria Incontinence: inability to control bladder Urinary suppression: stopping urination Anuria: absence of urine (<100 mL/day) Urinary retention: inability to empty bladder fully

ABNORMAL URINARY PATTERNS

Intact skin; redness typically over bony prominence; tissue swollen with possible discomfort; on darker skin, ulcer appears blue or purple.

Stage 1: nonblanchable erythema:

Dead tissue; damage of muscle, bone, and supporting structures; infection, tunneling, undermining, eschar (black scab-like), or slough (tan, yellow, green scab-like).

Stage 4: full-thickness:

Cannot determine stage because eschar or slough conceals the wound.

Unstageable, full-thickness

skin/tissue loss, depth unknown:

Extends to epidermis and dermis; red-pink superficial area; NO slough or bruising; looks like an abrasion or blister; edema; ulcer can become infected; pain and litt le drainage.

Stage 2: partial thickness:

Damage, dead subcutaneous tissue; drainage and infection are common.

Stage 3: full-thickness:

ENTERAL FEEDING

• Poor gag reflux (stroke, decreased LOC)
• Poor nutrient intake
• Trauma (burns) > increased nutritional needs
• Cancer affecting head, neck, and upper GI tract
• GI disorders (IBD, enterocutaneous fistula)

Reasons forventeral feeding?

• Aspiration!
• Gastric residual more than 250 mL (withhold feeding and notify HCP)
• Diarrhea 3x or more in 24 hrs.
• Infection or Bleeding at insertion site
• Dislodge of tube

Complications:

Nasogastric; Nasoduodenal; Nasojejunal:

• Inserted via nose
• Short-term (less than 4 wks.) Gastrostomy; jejunostomy:
• Long-term (more than 4 wks.)
• Inserted surgically Percutaneous endoscopic gastrostomy (PEG); percutaneous endoscopic jejunostomy (PEJ):
• Long-term (more than 4 wks.)
• Inserted endoscopically

Types:

- ASEPTIC TECHNIQUE

(avoid bacteria entering the GI tract)

• Semi or High Fowler’s position during & 30 mins after feeding
• Flush feeding tube with 15-30 mL (0.9% NS) before and after administering medication
• DO NOT crush a enteric coated or timerelease tablet and give by GI tube
• Flush tube with 30-50 mL (0.9% NS) every 4-6 hrs. if on continuous feeding to prevent clogging.

Nasogastric: give nose and mouth care

(clean nose, brush teeth, moisturize)

PEG: check skin integrity, for infection or drainage

To check placement: > x-ray > aspirate gastric content and measure pH.

Gastric pH is between 1.5-

Open System: formula from cans either bottles are bloused into feeding tube, fed via pump either gravity drip. Discard formula Q4 hrs.

Closed “Ready to Hang”: sterile, pre-filled formula containers that are spiked by the feeding tube and fed via pump.

Open Vs. Closed System

• Standard “Polymeric”: 1-2 kcal/ml
• Milk Based or Blenderized Foods
• Complete Nutrient Formula
• Requires patient to absorb entire nutrients
• Modular Formulas: 3.8-4 kcal/ml
• Need to Supplement with other foods since not nutritionally complete
• Preparation of a Single Macronutrient (protein, glucose, polymers, lipids)
• Elemental Formulas: 1-3 kcal/ml
• Used for partially dysfunctional GI tracts
• Contains predigested nutrients
• Specialty Formulas: 1-2 kcal/ml
• Used in patients with hepatic failure, respiratory disease, or HIV
• Meets specific needs related to individual illness

Enteral Formulas

• Diverticulitis

OSTOMY CARE

An ostomy is a surgical opening (stoma) in the abdominal wall that allows for the passage of stool and urine. It could be required because of:

• Irritable Bowel Disease
• Bladder Cancer • Colon Cancer
  • Ruptured Diverticulum
  • Traumatic Injury to Bowel/Rectum
• To limit the possibility of leaks and odors, empty the Ostomy Appliance when it is 1/3 - 1/2 filled.
• For redness or irritation, apply powder
• For additional assistance, contact a WOC (wound, ostomy, continence) nurse.
• The stoma may be large at first, but it will settle in size 6-8 weeks after surgery.
• Keep Skin C/D/I: clean, dry, intact
• Monitor for Signs of Dermatitis or Yeast infection
• Offer emotional support and encouragement for a new body image

Ostomy Care

To eliminate waste, a stoma is an opening in the abdominal wall attached to the redirected area of the digestive system (colon=colostomy, ileum=ileostomy).

Red-Pink: Normal Stoma Purple-Blue: Ischemia Pale Pink: Anemia

A pouch is a device that connects to the stoma to collect bowel contents (gas, feces).

Stoma & Pouch

Colostomy: diversion of the “Colon” of the large intestine It could be caused by IBD, Colorectal Disease, or Diverticulitis. There are three varieties: Descending: stool semi-formed Transverse: stool unformed Ascending: liquid stool

Ileostomy: "Ileum" diversion of the small intestine May be due to Colon Cancer, Polyps, Trauma. Amount of Output.

Types of Ostomies

Ileum

Transverse

Colostomy

Descending

Colostomy

Sigmoid

Colostomy

Ascending

Colostomy

Ileostomy Colostomy

AUSCULTATING LUNG SOUNDS & LANDMARKS

Vesicular

Bronchial

Bronchovesicular

VESICULAR

NORMAL

Soft, low pitched during inspiration and even softer during expiration

ABNORMAL

WHEEZE

High-pitched musical sound; heard more at expiration than inspiration Ex: Asthma

PLEURAL RUB FRICTION

Low-pitch, rubbing or grating sound; heard at both inspiration and expiration. Loudest over the lower anterolateral surface. Not cleared by cough Ex: Pleurisy (inflammation of pleural surfaces)

RHONCHI

Low-pitched, coarse, loud, snore-like; heard most ly at expiration. Clears with cough Ex: Chronic bronchitis

CRACKLES (RALES)

FINE: high-pitch crackling, popping noise heard during end of inspiration. Not cleared by cough Ex: Heart Faikure, Pneumonia

COARSE: low-pitched, bubbling or gargling sounds at early start of inspiration and expiration. Louder and lasts longer than fine crackle Ex: Pulmonary Embolism

BRONCHIAL

Hollow; high-pitched compared to vesicular sounds; auscultated over the trachea

BRONCHOVESICULAR

Equal, normal sounds; mixture of bronchial and vesicular; auscultated over bronchi (between trachea and alveoli of lungs)

PAIN MANAGMENT

A patient's response to and perception of pain can vary. Everyone interprets pain differently, and the patient's self-report of pain is the most reliable predictor.

Acute Pain: <6 months and causes sympathetic “fight or flight” symptoms such as increased HR/BP, anxiety, diaphoresis. Chronic Pain: >6 months and has no effect on vital indicators. Chronic pain can also be idiopathic (no known cause).

Acute vs. Chronic

Nociceptive Pain: normal pain processing from a stimulus. There are 3 variations:

• Somatic: Subcutaneous tissue or skin Sx: Localized and Sharp. Ex: Cut Finger
• Visceral: the lining of organs and internal organs. Sx: Dull, Deep, Aching. Ex: MI
• Referred: detected in a location other than the origin Ex: Shoulder Pain from MI

Neuropathic Pain: abnormal pain processing caused by dysfunctional or damaged pain nerves There are 3 variations:

• Diabetic Neuropathy: Diabetes causes severe, shooting, scorching, and "pins and needles" sensations in the limbs.
• Phantom Pain: limb amputation pain

Nociceptive vs. Neuropathic

Pain Threshold: min amount of pain before felt Pain Tolerance: max amount of pain a person can bear Modulation: nerves of the spinal cord cause muscles to contract away from area of painful stimuli. Transduction: conversion of pain to an electrical impulse through peripheral nerve fibers (nociceptors). Transmission: electrical impulse travels along nerve fibers

Terms to Know

FACES: most common for adults and children 3+ CRIES: 0-6 months COMFORT: Intubated pts (objective findings) NUMERICAL PAIN SCALE: 0-10 pain scale. PAINAID: ALZHEIMERS FLACC: 2 mo - 7 yrs for nonverbal face, legs, activity, cry, consolability.

Pain Scales

No Pain Mild Moderate Severe Very Severe

Worst Pain Possible

Opioids for Severe Pain +/- Adjuvants or Non-Opioids Pain Increases Opioids for Mild to Moderate Pain +/- Adjuvants or Non-Opioids Pain Increases Non-Opioids: NSAIDs or Tylenol +/- Adjuvants: Gabapentin, Amitriptyline

Pain Management

Nonpharmacological

Heat/Cold Massage Imagery

Distraction Acupuncture

NOTES